2007年8月31日 星期五

A Chef Faces His Worst Fears

A Top Creator of Exotic FlavorsBattles Tongue Cancer

By JANET ADAMYAugust 31, 2007; Page B1 WSJ

Chicago

A year after chef Grant Achatz opened Alinea here in 2005, Gourmet magazine named the restaurant the best in the country, and the prestigious Mobil guide gave it its highest rating of five stars. The young chef's exotic, lavishly presented creations -- a mango duck dish is served on a deflating pillow that releases lavender-scented air -- have connoisseurs lining up to book meals that cost an average of $240 a person.

But last month, doctors gave Mr. Achatz, 33 years old, devastating news. A cancerous tumor was growing inside his tongue. The disease was so advanced that three doctors told him the only way to cure it was to cut out part of his tongue, leaving one of the world's most celebrated chefs to ponder life without the ability to taste.

Janet Adamy

"I was just in disbelief," says Mr. Achatz (pronounced ACK-etz). There are about 35,000 cases of head and neck cancer a year in the U.S., and most afflict older people and smokers. "I've never had a cigarette in my mouth in my life," Mr. Achatz says.

The diagnosis sent him looking for an alternative treatment that would save his life and his tongue. The tumor had made it so painful to chew that Mr. Achatz couldn't eat solid food and had lost at least 10 pounds.

Saving his tongue hinges on whether a team of doctors at the University of Chicago can cure the cancer using an atypical method of treatment. Instead of the standard therapy -- removing the tumor surgically, followed by radiation and chemotherapy -- his doctors are starting with a course of chemotherapy that adds a drug called cetuximab to two more conventional drugs. Then they will follow that with a combination of radiation therapy, more chemotherapy, and drugs.

Everett Vokes, one of the oncologists treating the chef, says there is a 70% chance of recovery for these types of cancers, though he won't give odds for Mr. Achatz. If the treatment doesn't cure him, doctors will have to consider removing part of his tongue.

Mr. Achatz, skinny and boyish with scraggly auburn hair, says he is optimistic about his recovery, is feeling great and is determined not to let his illness slow him down. Alinea's owners stress that so far, nothing has changed at the restaurant, and that they don't anticipate it will. Despite starting a typically tiring regime of chemotherapy a month ago, Mr. Achatz continues to spend long days creating and preparing dishes at Alinea, sometimes staying past 3 a.m. Already the treatments have improved his condition enough that he can chew more comfortably.

He grew up helping his parents prepare family-style dishes at their St. Clair, Mich., restaurant. After graduating from the Culinary Institute of America in New York, he worked under chef Thomas Keller at the prestigious French Laundry restaurant in Yountville, Calif., then became the head chef at Trio in Evanston, Ill., north of Chicago.

It was there that his avant-garde creations began to attract critical plaudits. In 2002, Chicago Tribune restaurant critic Phil Vettel wrote a rave four-star review of Trio, singling out a miniature ice-cream sandwich of parmesan-laced shortbread wafers around savory olive-oil ice cream that Mr. Achatz sent to his table as a starter.

In 2004, Mr. Achatz detected a tiny sore growing on the side of his tongue. A dentist told him it was probably from unconsciously biting at the spot, and fitted his mouth for a night guard. That year, he left Trio to open his own restaurant in Chicago's tony Lincoln Park neighborhood.

He decided to call it Alinea, after the name for a typographical symbol that indicates a new train of thought. His ambition wasn't only to present his food as art, but to make the entire dining experience into a form of theater that would appeal to all of diners' senses and elicit emotional responses. For instance, Mr. Achatz had an architect design Alinea's entrance so that people would walk in, not be able to see the dining room and briefly think they were someplace other than the restaurant, creating a moment of tension.

As soon as Alinea opened in 2005, critics began heaping praise on the hypermodern cuisine and eclectic dining experience. Meals consist of as many as 30 small courses and have taken diners more than seven hours to consume.

To evoke autumn, Mr. Achatz served a piece of pheasant breast on an oak-tree branch lit on fire so it would be smoking as it arrived at the table. For a dish called "Hot potato, cold potato," Mr. Achatz skewered a marble-size potato and suspended it over a paraffin wax bowl of chilled potato soup so the palate would sense the temperature contrast.

But as Mr. Achatz's reputation grew, his ability to eat was deteriorating. By May, the sore on his tongue was causing him so much pain that it was difficult for him to talk and bite into solids. He had trouble eating one of his favorite foods, pizza.

One day in July, doctors told him it was stage-4b squamous cell carcinoma of the oral tongue. Mr. Achatz says he brooded for a day, then set out to find an alternative to surgery.

"I never said, 'I'm done,' or 'What am I going to do?', or 'Do I have to change careers?'" he says.

Dr. Vokes says it's too early to predict exactly what might happen if doctors removed the tumor from Mr. Achatz's tongue. Typically, removing a significant part of the tongue leaves a patient unable to taste and interferes with his or her ability to speak and to swallow. The sense of smell isn't usually affected.

But other senses contribute to Mr. Achatz's talent. Much of his acclaim derives from the way his dishes look. Before he cooks a new creation, he writes down the ingredients he wants to use and how he'll manipulate them. Then, he sketches what it might look like on the plate before discussing it with the chefs who work under him.

"He has such a spiritual connection with food and the visuals, and the taste is just a part of it," says Rick Tramanto, executive chef at Tru in Chicago. "He's way too connected to what he's doing to have [a loss of] one of the elements deter him at all."

Associates say it is Mr. Achatz's passion, not just his senses, that make his food successful. "You could take out his tongue and his eyes, and it would be Grant's restaurant," says Nick Kokonas, co-owner of Alinea. "I can't imagine that he wouldn't be able to overcome any limitations." Mr. Kokonas says they're laying plans to open a second Chicago restaurant, and that he'd "love to do something like Alinea in San Francisco."

Next month, Mr. Achatz will begin the more intensive combination of chemotherapy and radiation treatments that could slightly dull his ability to taste, though Dr. Vokes says taste gradually returns to patients after the treatments stop.

One recent night at the restaurant, he hunched over a row of white platters assembling short ribs with a topping of peanuts and a Guinness-flavored covering. Moving intently from dish to dish, he broke his concentration only to call out instructions -- "You bringing lamb, or what?" -- then refocused on his task.

As he sees it, tackling cancer isn't much different. "The thought process that goes into building these dishes are little miniversions of what I face with my illness," he says. "Your mind just deconstructs it and pulls it apart, and you're left with the same challenges you face every day."

2007年8月29日 星期三

Code Blue: A Medical Morality Play in 3 Acts

By LARRY ZAROFF, M.D.

Published: August 28, 2007 紐約時報

Code Blue, Code Blue, blasting over the hospital loudspeaker. Of course, it’s hardly a code. Everyone knows what it means: a patient is dying.

It was the fall of 1961, a typical day at Mount Auburn Hospital in Cambridge, Mass., where I was a surgical resident. When I heard the Code Blue bugle call, I ran up two flights to a private room, where a respiratory therapist and a nurse were desperately trying to keep the patient alive, punishing him with blow after blow to the chest.

I took the shards of his history. A slender man in his 40s who’d been doing well after a first heart attack, until — bingo. His heart just stopped.

I took over, asking for the usual: check oxygen level, call anesthesia to insert breathing tube, get the defibrillator, notify the family — “tenderly, please, just say ‘turn for the worse, please come back to the hospital.’ ” The defibrillator arrived (“Everyone away!” “Hit it!”) and current flowed through the patient, a tsunami of an electric wave.

Suddenly he rose with a jerk, traveling on the crest of the wave back to normal rhythm , and before long he’d stabilized. By Day 3 he was talking, moving arms and legs, recognizing his family. I peeked in to say hello. He nodded, seeming wary, and I too felt cautious. Why tell him I resuscitated him, remind him he almost died?

•

Four years passed. In the summer of 1965 I returned to Boston after a hitch in the Army. We had two small children, a third on the way, and we found a promising rental on the lower floor of a house in a Boston suburb — a nice place, spacious even, compared with officers’ housing.

During surgical residency, I’d learned to control the startle reaction. Don’t raise your head from the exposed heart even if the orderly knocks over the rinse basin or the nurse drops a tray of instruments. I had learned that calm worked best. I was not perfect the day we faced our prospective landlord. My head jumped back, my eyes widened. He did not notice; he had no idea we’d met the day his heart stopped.

After my shock passed, I had the same thought I’d had back then: “Why tell him? Surely he has suffered enough.” We signed the lease. Over the next 12 months I saw him regularly, working in the garden, taking out the trash. The heavy work belonged to his wife, a quiet lady who seemed to carry her grief past sadness, to an anticipation of future sorrow. By June I had a real job, a decent salary, and we were moving again.

We had left a deposit when we signed the lease. Now the landlord checked the apartment like a lion after a wildebeest, zeroing in on the fireplace, where our oldest children had decorated the white mantel in a motley design of red, orange and blue crayon.

He turned toward me. He became adjacent and angry. “You owe me $300,” he snarled, shaking with each word.

What to say now? Should I let my own rage speak — “You idiot, $300 to paint a mantel? I saved your life!” We had no extra money; I’d counted on the same $300 for the trip to our new home.

I took a deep breath, and I gently asked him if he remembered his heart attack.

“Yes, sure.”

“Do you know your heart stopped?”

“I think so.”

“Well, I was the one who saved your life, brought your heart back.”

He hesitated. “I didn’t know that.”

He turned to the door, distressed, in pain. Turned again. “You still owe me $300.”

•

We paid. He had his old life. We had our new lives.

Older now, I would not have told him. In 40 years of practicing and teaching, I’ve learned this much: his agony was not worth $300 to either of us.

Larry Zaroff teaches medical humanities to undergraduates and medical students at Stanford.

NO surprises” is a basic rule in hospitals. Junior doctors are supposed to notify their superiors promptly about worrisome developments in a patient, and information is supposed to move smoothly up the chain of command. One of the gravest errors a doctor in training can make is to inform the attending physician well after the fact about a patient’s turn for the worse.

Unfortunately, this rule does not extend to seriously ill patients themselves. They and their families are frequently surprised by the sudden imminence — and the raging authority — of death.

Research has revealed doctors’ tendency to contribute to the problem by avoiding making prognoses. In one study of nearly 5,000 hospitalized adults who had roughly six months to live, only 15 percent were given clear prognoses. In a smaller study of 326 cancer patients in Chicago hospices, all of whom had about a month to live, only 37 percent of the doctors interviewed said they would share an accurate prognosis with their patients, and only if patients or their families pushed them to do so.

Even when doctors do prognosticate, the research shows, they typically overestimate the time a patient has left to live, often at least tripling it, perhaps because they feel overconfident. The pugilistic attitude most doctors adopt toward disease is understandable, even desirable, for much of the course of illness. But there comes a time when this attitude can lead to false optimism. Doctors who wrongly think that patients are going to live much longer wind up recommending needlessly painful and expensive treatments. This phenomenon is neatly captured by a gallows-humor joke told by hospice nurses: Why are coffins nailed shut? To keep doctors from administering more chemotherapy.

By not making or communicating prognoses, doctors can make the end of life more unpleasant. Patients are given no chance to draft wills, see distant loved ones, make peace with estranged relatives or even discuss with their families their wishes about how to live the end of their lives. And they are denied the chance to make decisions about what kind of medical care they want to receive.

Roughly half of Americans die with inadequately treated pain. Large minorities suffer symptoms like shortness of breath, nausea or depression. Four in five die in hospitals and nursing homes, rather than at home as most prefer. And more than half significantly burden family caregivers in the course of their final illness: the family loses its life savings, a caregiver has to quit work or a spouse falls seriously ill.

For reliable prognoses to become a routine part of medical care they must become a priority of medical research and education. Less than 5 percent of research focuses on prognosis. Textbook descriptions of diseases cover prognosis less than 25 percent of the time. And medical schools and residency programs almost completely neglect training in prognostication.

Greater investments in new statistical tools and databases that help physicians predict outcomes are also needed. With these, doctors could translate the clinical, biochemical and genetic information they collect on their patients into statistical predictions of life expectancy that could supplement their own clinical judgment.

Doctors often say they worry that predictions about survival may become self-fulfilling prophecies or cause patients to lose hope. But a realistic assessment of how long a patient has to live need not cause either the patient or doctor to become pessimistic. It should only refocus attention on the quality of the patient’s life. Sometimes living life to its fullest requires knowledge of its finitude.

Nicholas A. Christakis, a physician and a professor of sociology at Harvard, is the author of “Death Foretold: Prophecy and Prognosis in Medical Care.”

UK scientists say they have discovered a new way to regulate blood pressure, offering hopes of new drugs to combat strokes and heart attacks.

One in four adults has high blood pressure and although powerful drugs are already available, few manage to achieve target blood pressure levels.

The pathway found in a study by King's College London involves a process called oxidation, reports Science.

Until now, oxidation has largely been linked with harm rather than good.

Indeed, free radicals and oxidants, such as hydrogen peroxide, can cause cell damage.

But they also play crucial roles in normal cell function.

Blood pressure control

Protein kinase G (PKG) is an important protein in all tissues, but in the cardiovascular system it plays a fundamental role in blood pressure regulation.

Nitric oxide produced within blood vessels is known to be crucial in this process.

But Joseph Burgoyne and colleagues at King's College have found a novel way in which the protein PKG can be regulated independently of nitric oxide.

The team's novel discovery opens up opportunities for the design of new drugs to combat high blood pressure

The British Heart Foundation

They discovered that oxidants such as hydrogen peroxide cause a bond to form between two amino acids which, in turn, activates PKG. This then leads to a lowering of blood pressure.

Dr Philip Eaton, who led the King's team, said: "The research could lead to the development of drugs which activate this new pathway."

The researchers now plan to explore the role of this new pathway in the events leading to a heart attack.

Professor Jeremy Pearson, Associate Medical Director of the British Heart Foundation, which funded the research, said: "This research is exciting. Firstly, the team's novel discovery opens up opportunities for the design of new drugs to combat high blood pressure.

"Secondly, the mechanism provides new insights into how oxidant stress affects cells and tissues. Oxidant stress not only alters blood flow, but also affects the heart's ability to contract and is involved in a wide variety of inflammatory conditions."

Oxidation May Be New Blood Pressure Regulator

A novel way of regulating blood pressure has been discovered by British scientists. This breakthrough could lead to innovative drugs that fight heart attacks and stroke.

One quarter of UK adults suffer from hypertension (high blood pressure). Despite being treated with potent medication, many never manage to get their blood pressure levels back to normal.

Scientists at King's College London have found a pathway which involves oxidation. You can read about this in the journal Science.

Oxidation is a term we usually associate with free radicals and oxidants, which are harmful and cause cell damage. However, oxidation is central to normal cell function, say the scientists.

PKG (protein kinase G) plays a crucial part in regulating our blood pressure. We know that nitric oxide, which is produced inside our blood vessels, is a vital part of this process. The scientists, lead by Joseph Burgoyne, have discovered a new way PKG can be regulated without nitric oxide being involved.

Hydrogen peroxide, the scientists found, triggers a bond between two amino acids which activate PKG - resulting in lower blood pressure. They say this discovery could eventually lead to new drugs which activate this new pathway.

They would like to see what role this new pathway has in events that take place before the onset of a heart attack.

2007年8月24日 星期五

Many Found Sexually Active Into the 70s

Most Americans remain sexually active into their 60s, and nearly half continue to have sex regularly into their early 70s, researchers are reporting today as a result of the most comprehensive national survey to date of sexual behavior among older adults.

But many older people also report struggling with sexual problems, like reduced desire and erectile difficulties, the survey found.

The new report, appearing in The New England Journal of Medicine, was based on interviews with more than 3,000 Americans, 57 to 85 years old, who gave detailed descriptions of their sexual activities.

It found that for varied reasons, women were significantly less likely than men to report being sexually active from age 57 on. Women were more often without a partner, for example, and were more likely to say they no longer derived much pleasure from sex.

Experts said that the new survey provided the first clear and complete picture of sexuality in later life and that it should give older adults a sense of where they stand compared with their peers. Researchers have done previous surveys of sexual activity among older people, but those studies were of patients or other groups who were not nationally representative.

“There’s a large perception out there that sex somehow does not occur in the later years, and this study demonstrates authoritatively that for many people sexual activity does not diminish much at all,” said Dr. Robert N. Butler, president of the International Longevity Center in New York and co-author with his late wife, Myrna I. Lewis, of “Love and Sex After Sixty.”

“Human relationships are important to the very end,” said Dr. Butler, who was not involved in the study.

The researchers, at the University of Chicago and the University of Toronto, contacted by letter a representative group of 3,005 older adults across the country. Trained interviewers then conducted a two-hour face-to-face session with each of these men and women, asking about their sexual activities as well as their physical and social health and other aspects of their lives.

The study, financed partly by the National Institutes of Health, found that 84 percent of men from 57 to 64 reported having had some sexual contact with another person in the last year, compared with 62 percent of women in the same age group. Those figures dwindled to 38 percent and 17 percent, respectively, in people 75 and older.

But among those adults who were sexually active, about two-thirds had sex at least twice a month into their 70s, and more than half continued at that pace into their 80s.

The lead author, Dr. Stacy Tessler Lindau, an assistant professor of obstetrics, gynecology and geriatrics at the University of Chicago, said the findings should give people a way to gauge their own experiences and might prompt those with questions or problems to ask their doctors.

Nearly half of those who were sexually active reported at least one sexual problem, with 43 percent of women reporting diminished desire, and 39 percent vaginal dryness, and with 37 percent of men reporting erectile difficulties.

But only about a third of the men and just a fifth of the women in the study had discussed sex with a doctor since age 50.

2007年8月22日 星期三

Cancer care

Aug 22nd 2007From Economist.com

CANCER patients' chances of survival vary widely among European countries. Franco Berrino and a team of researchers from Eurocare studied the outcome of 2.7m new cases diagnosed between 1995 and 1999 in 23 countries. Five years after diagnosis, survival rates were highest overall in the Nordic region (except Denmark) and lowest in central Europe. Health spending is a factor, with higher national expenditure usually correlating with higher survival rates. Denmark and Britain are exceptions. They have lower rates than those in countries with similar levels of spending, perhaps suggesting ineffective use of resources. The findings are published in the latest issue of the Lancet Oncology.

2007年8月20日 星期一

Looking Past Blood Sugar to Survive With Diabetes

Dave Smith found out he had Type 2 diabetes by accident, after a urine test.

“Whoa, look at the sugar in here,” his doctor told him. Mr. Smith’s blood sugar level was sky high and glucose was spilling into his urine.

That was about nine years ago, and from then on Mr. Smith, like so many with diabetes, became fixated on his blood sugar. His doctor warned him to control it or the consequences could be dire — he could end up blind or lose a leg. His kidneys could fail.

Mr. Smith, a 43-year-old pastor in Fairmont, Minn., tried hard. When dieting did not work, he began counting carbohydrates, taking pills to lower his blood sugar and pricking his finger several times a day to measure his sugar levels. They remained high, so he agreed to add insulin to his already complicated regimen. Blood sugar was always on his mind.

But in focusing entirely on blood sugar, Mr. Smith ended up neglecting the most important treatment for saving lives — lowering the cholesterol level. That protects against heart disease, which eventually kills nearly everyone with diabetes.

He also was missing a second treatment that protects diabetes patients from heart attacks — controlling blood pressure. Mr. Smith assumed everything would be taken care of if he could just lower his blood sugar level.

Blood sugar control is important in diabetes, specialists say. It can help prevent dreaded complications like blindness, amputations and kidney failure. But controlling blood sugar is not enough.

Nearly 73,000 Americans die from diabetes annually, more than from any disease except heart disease, cancer, stroke and pulmonary disease.

Yet, largely because of a misunderstanding of the proper treatment, most patients are not doing even close to what they should to protect themselves. In fact, according to the federal Centers for Disease Control and Prevention, just 7 percent are getting all the treatments they need.

“That, to me, is mind-boggling,” said Dr. Michael Brownlee, director of the JDRF International Center for Diabetic Complications Research at the Albert Einstein College of Medicine in New York. “It makes me ask, What is going on? I can only conclude that people are not aware of their risks and what could be done about them.”

In part, the fault for the missed opportunities to prevent complications and deaths lies with the medical system. Most people who have diabetes are treated by primary care doctors who had just a few hours of instruction on diabetes, while they were in medical school. Then the doctors typically spend just 10 minutes with diabetes patients, far too little for such a complex disease, specialists say.

In part it is the fault of proliferating advertisements for diabetes drugs that emphasize blood sugar control, which is difficult and expensive and has not been proven to save lives.

And in part it is the fault of public health campaigns that give the impression that diabetes is a matter of an out-of-control diet and sedentary lifestyle and the most important way to deal with it is to lose weight.

Most diabetes patients try hard but are unable to control their disease in this way, and most of the time it progresses as years go by, no matter what patients do.

Mr. Smith, like 90 percent of diabetes patients, has Type 2 diabetes, the form that usually arises in adulthood when the insulin-secreting cells of the pancreas cannot keep up with the body’s demand for the hormone. The other form of diabetes, Type 1, is far less common and usually arises in childhood or adolescence when insulin-secreting pancreas cells die.

And, like many diabetes patients, Mr. Smith ended up paying the price for his misconceptions about diabetes. Last year, he had a life-threatening heart attack.

The Heart Disease

Just after returning from church last October, Mr. Smith had a discomforting sensation. Deciding to focus on something else, he went to a local newspaper office where he was weekend editor. But the strange feeling persisted and intensified.

“I felt a pain in my chest,” Mr. Smith recalled. “It wasn’t sharp — it was more of a kind of pressure, a feeling like something is contracting.”

The pain spread, to his neck, along his shoulder, down to his biceps. Mr. Smith, alone and frightened, looked up heart attack symptoms on the American Heart Association’s Web site. They were exactly what he was experiencing.

An hour later, Mr. Smith was at the Mayo Clinic in Rochester, Minn., in the throes of a major heart attack, transported by helicopter while his wife and two young sons frantically drove two and a half hours to be with him. A main artery to his heart was 90 percent blocked. If he had waited to seek help or if his local hospital and doctor had not acted quickly and sent him to the Mayo Clinic, he probably would have died.

Mr. Smith thought his biggest risk from diabetes was blindness or amputations. He never thought about heart disease and had no idea how important it was to control cholesterol levels and blood pressure. He said his doctor had not advised him to take a cholesterol-lowering or blood pressure drug and he did not think he needed them.

Most people with diabetes are equally unaware of the danger that heart disease poses for them.

A recent survey by the American Diabetes Association conducted by RoperASW found that only 18 percent of people with diabetes believed that they were at increased risk for cardiovascular disease.

Yet, said Dr. David Nathan, director of the Diabetes Center at Massachusetts General Hospital, “when you think about it, it’s not the diabetes that kills you, it’s the diabetes causing cardiovascular disease that kills you.”

Dr. Brownlee said he was stunned by the results of the diabetes association poll. “If you are one of those 82 percent who don’t think you are at increased risk,” he said, “finding out that you are and that you can decrease that risk substantially could literally change your life.”

The science is clear on the huge benefits for people with diabetes of lowering cholesterol and controlling blood pressure. After multiple studies, costing hundreds of millions of dollars and involving tens of thousands of subjects, national guidelines were rewritten to reflect the new data, and professional organizations issued recommendations for diabetes care.

With cholesterol, the guidelines say that levels of LDL cholesterol, the form that increases heart disease risk, should be below 100 milligrams per deciliter and, if possible, 70 to 80. Yet, Dr. Brownlee said, diabetes patients with LDL cholesterol levels of 100 to 139 often are told that their levels — ideal for a healthy person without diabetes — are terrific.

“Many practicing doctors just don’t know that an LDL cholesterol number that is normal for someone without diabetes is not normal for someone with diabetes,” he said.

Mr. Smith found all that out too late. The heart attack, he said, “really blindsided me.”

He also did not know the other measures proven to prevent complications in diabetes. He was correct that high blood sugar is dangerous. It can damage the small blood vessels in the eyes, leading to blindness; the nerves in the feet, leading to amputations; and the kidneys, leading to kidney failure.

But no matter how carefully patients try to control their blood sugar, they can never get it perfect — no drugs can substitute for the body’s normal sugar regulation. So while controlling blood sugar can be important, other measures also are needed to prevent blindness, amputations, kidney failure and stroke. Mr. Smith was doing none of them.

He also made the common assumption that Type 2 diabetes is simply a consequence of being fat. And that losing weight will help cure it.

Obesity does increase the risk of developing diabetes, but the disease involves more than being obese. Only 5 percent to 10 percent of obese people have diabetes, and many with diabetes are not obese. To a large extent, Type 2 diabetes is genetically determined — if one identical twin has it, the other has an 80 percent chance of having it too. In many cases, weight loss can help, but, as Mr. Smith has learned, most who lose weight are not cured of the disease. He lost 40 pounds but still has diabetes.

“Everybody in the act of losing weight will have a pretty dramatic improvement pretty quickly,” said Dr. C. Ronald Kahn, a diabetes researcher and professor of medicine at Harvard Medical School. Blood sugar levels drop precipitously and the disease seems to be under control. But that is because the metabolic process of weight loss lessens diabetes. Once weight is lost, he added, and people stabilize at a lower weight, their diabetes may remain.

When it comes to weight loss, Dr. Kahn said, “there is a range of susceptibilities in how people react.”

Complex Regimens

Before he left the hospital, Mr. Smith’s doctors told him about his new diabetes regimen: a statin to drive his cholesterol level very low, two drugs to lower his blood pressure, an aspirin, insulin and two drugs to reduce his blood sugar levels. That new list of drugs was what he should have been taking all along.

Mr. Smith is taking them now, terrified that his heart disease will progress.

The statistics are grim: A quarter to a third of all heart attack patients have diabetes, even though diabetes patients constitute just 9.3 percent of the population. Another 25 percent of heart attack patients are verging on diabetes with abnormally high blood sugar levels.

Most worrisome are diabetes patients who already have symptoms of heart disease, like chest pains or a previous heart attack. “That is a terrible situation,” said Dr. James Cleeman, coordinator of the National Cholesterol Education Program at the National Institutes of Health. Those patients, Dr. Cleeman said, are set up for a fatal heart attack and should be stringently controlling their cholesterol and blood pressure.

And it is not just that many diabetes patients are overweight, as people with Type 1 diabetes, who often are thin, also have a high risk of heart disease. There is something about diabetes itself, researchers say, that leads to high levels of LDL cholesterol and a form of LDL cholesterol particles that is particularly dangerous. Diabetes also leads to increased levels of triglycerides, which are fats in the blood that increase heart disease risk, and in diabetes is linked to high blood pressure.

Being obese or overweight, in contrast, are “weak contributors to heart attack risk,” Dr. Nathan said.

Somehow, though, it has taken quite a while for the alarm bells to go off.

One reason might be that it was heart disease researchers, not diabetes researchers, who conducted the seminal studies.

The key to saving lives is to reduce levels of LDL cholesterol to below 100 and also control other risk factors like blood pressure and smoking. The cholesterol reduction alone can reduce the very high risk of heart attacks and death from cardiovascular disease in people with diabetes by 30 percent to 40 percent, Dr. Cleeman said. And clinical trials have found that LDL levels of 70 to 80 are even better for people with diabetes who already have overt heart disease.

Studies of blood sugar control have been more problematic than those of cholesterol lowering.

In Type 2 diabetes, the most ambitious effort was a huge study in Britain. It found that rigorous blood sugar control could lower the risk of complications that involved damage to small blood vessels, a list that includes blindness, nerve damage and kidney damage. But there was no effect on the overall death rate. There was a small decrease in the number of heart attacks but it was not statistically significant, meaning it could have occurred by chance.

The National Institutes of Health is trying again, with a larger study of blood sugar control that includes enough patients to detect more subtle effects on the heart attack rate if they exist. For now, though, the answer simply is not known.

In Type 1 diabetes, a large federal study did find evidence that rigorous blood sugar control could reduce heart disease risk. But the effect emerged 12 years after the study ended and most of the patients, in those years, had not been able to sustain the blood sugar control that they had had during the study. Did the short period of rigorous control exert a delayed effect on heart disease or was the effect caused by some other factor during the study or afterward, some asked? While most think it was caused by blood sugar control, it is impossible to know for sure.

The result, notes Dr. John Buse, president-elect for science and medicine at the American Diabetes Association, is that for people with Type 1 and, especially, for those with Type 2 diabetes, there are still questions about whether and to what extent blood sugar control protects against heart disease and saves lives.

That leaves cholesterol lowering, for patients with Type 1 and Type 2 diabetes, as the most effective and easiest way by far to reduce the risk of heart disease and the only treatment proven to save lives. But doctors say achieving the recommended cholesterol levels usually means taking a statin. Some patients resist, wary of intense drug company marketing to patients and afraid of side effects like muscle or liver damage which, although extremely rare, have frightened many away from the drugs, Dr. Brownlee and other diabetes specialists said. (Dr. Brownlee said he had no financial ties to statin makers.)

Others point to drug company advertising itself.

Statin advertising, said Dr. Irl B. Hirsch, a professor of medicine and director of the diabetes clinic at the University of Washington, is all about heart disease, and the advertisements do not mention diabetes. The diabetes advertisements are all about blood sugar. Dr. Hirsch has seen few that put the two together.

Yet lowering cholesterol with statins, Dr. Hirsch and others said, is much simpler than anything else diabetes patients are asked to do. And, he added, the drugs are among the best studied and the safest on the market. (Dr. Hirsch said he had no financial ties to statin makers.)

Dr. Hirsch has a message for diabetes patients: If he had to rate the different regimens for a typical middle-age person with Type 2 diabetes, the first priority would be to take a statin and lower the LDL cholesterol level.

Dr. Brownlee agreed, but added that the two other measures to protect against heart disease, blood pressure control and taking an aspirin to prevent blood clots, should not be neglected.

“Right now, without waiting for lots of exciting things that are almost in the pipeline or in the pipeline, starting tomorrow, if everyone did these things — taking a statin, taking a blood pressure medication, and maybe taking an aspirin — you would reduce the heart attack rate by half.”

The Burnout

Even when patients do take the right steps to control diabetes, the grueling process can simply wear them down.

Virgil Umbarger learned that he had Type 2 diabetes when he was 39 and had a medical exam for a life insurance policy.

That was 25 years ago, and the start of a journey that diabetes specialists say ends up fundamentally changing a person’s world. Unlike Mr. Smith, who has just awakened to the danger he is in, Mr. Umbarger, a funeral director in Yakima, Wash., has lived with diabetes and its increasingly complex regimen for decades. And, as happens with most diabetes patients eventually, he feels he is reaching a point where he just cannot continue to do all that he should to protect his health.

In a sense, Mr. Umbarger said, he was not completely surprised when he learned he had diabetes, because it runs in his family. But he never thought it would happen to him. At 6 feet tall and 195 pounds, he was not heavy.

Still, Mr. Umbarger’s first thought was to lose weight. “I starved myself,” he said, and lost 15 pounds. But he still had diabetes and the pounds crept back on.

Dr. Buse said his patients knew how important it was to diet and exercise, but most could not do it enough to make a difference, and some were also thwarted by medications to control blood sugar that make patients gain weight.

In the end, Mr. Umbarger decided to seek care from a diabetes specialist. He chose Dr. Hirsch, even though it meant driving nearly three hours each way for an office visit. There was no one nearby with that kind of expertise, Mr. Umbarger said.

On his first visit, Dr. Hirsch gave him a fistful of prescriptions, including a statin, blood pressure medications and one for the drug Mr. Umbarger dreaded — insulin. He also told Mr. Umbarger to have regular checks for eye, nerve and kidney damage. And he has to watch what he eats and count carbohydrates.

Dr. Hirsch and other diabetes specialists say they are well aware of how daunting the program can be.

Not Mr. Umbarger. For years, he tried to do all that was required. He can cope with the medications and the long drives to see Dr. Hirsch. The problem for him, as for most diabetes patients eventually, is the blood sugar monitoring. He is supposed to prick his finger six or more times a day to measure his glucose levels and adjust his insulin dose accordingly.

Every time he checks his blood sugar is like getting a report card — was he eating too many carbohydrates? Did he get the insulin dose right?

“I don’t want to look,” he said.

“Pricking your finger, seeing that number day after day, it wears on you,” Mr. Umbarger said. “It’s like a ball and chain.” He confesses that he has only been checking his blood sugar once or twice a day, guessing at many of his insulin doses. His blood sugar levels have been rising and guilt hangs over him.

Meanwhile, no matter what they do, most people with Type 2 diabetes get worse as the years go by. Patients make less and less insulin and their cells become less and less able to use the insulin they do produce.

“That is why it is not uncommon to start initially with diet therapy, then after a few years we need to add a drug that improves insulin sensitivity,” Dr. Kahn said. “Then when that drug isn’t enough, we add a second drug that improves insulin sensitivity by a different mechanism. Then we add a drug that stimulates that pancreas to make more insulin.”

Then, he added, patients with Type 2 diabetes may need insulin itself, but when that happens they have to take even more than a person with Type 1 diabetes — two or even three times as much — because their cells no longer respond adequately to the hormone.

While it is not easy to re-energize burned-out patients, Dr. Hirsch said, at the very least, doctors and patients should know what is important.

“We already have the miracle pills” — statins and blood pressure medications, he said. And they are available for pennies a day, as generics.

“We need patient education and physician training that this stuff is out there and this is what we should be focusing on to make a difference in lives.”